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1. SAGE <br /> Distance to Public Sewers Connection necessary: Yes No,_ <br /> Does existing septic system comply with Ord. #549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> 2. WATER SUPPLY <br /> Is Water supplied. b_y private well: Yesiio Is well proper: <br /> Yes No State deficiency: <br /> Doea ,g ting or porposed use make this:,uell pub c Water. Yes- <br /> No- <br /> Yes <br /> No �'" Sample <br /> of well water taken: Yes No Date taken <br /> Results Additional information or. commento <br /> 3 . GARBAGE AL-HEME <br /> Licenced scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLY. M0,50UITO OR VECTnR POTENTIAL <br /> State possible vector potential necessary control: <br /> 5 . TOILET/BATH fACILITES <br /> No. & location existing: a2 _ Additional <br /> facilities needed <br /> 6. PRKYTOUS OPERATION HTSTOEX <br /> 7. GENERAL�56111TAITON. � ���� <br /> State any problems not previously noted: <br /> S . EMULA110 MaTjv, <br /> Appx. No. People per .sq. mi. <br />